The theme of this year's World Malaria Day, April 25, is “Harness innovation to reduce the malaria disease burden and save lives.” WHO is calling for investment and innovation in vector control, diagnostics, and treatments to help countries eliminate malaria after several years of stalled progress. In 2015, the World Health Assembly adopted a strategy to guide efforts towards elimination. But the first milestone—to achieve a 40% global reduction in malaria mortality rate and case incidence by 2020—was missed. Funding for malaria control has levelled off. Malaria mortality and incidence rates have not changed appreciably since 2015. There were an estimated 627 000 malaria deaths and 241 million malaria cases in 2020 (a 12% and 7% increase, respectively, compared with 2015). Given the stagnation of recent years, what cause is there to hope for a real change now?
The devastating setbacks to malaria programmes resulting from the COVID-19 pandemic might prompt a pessimistic answer. In April, 2020, WHO projected a doubling of malaria deaths during the pandemic if no actions were taken. Major global health organisations working on malaria—led by the Global Fund, along with the RBM Partnership to End Malaria, and the US President's Malaria Initiative—put together the COVID-19 Response Mechanism, a massive effort to restructure resources and activities to avert the worst-case scenario. Still, there were 14 million more malaria cases and 69 000 more deaths in 2020 compared with 2019. An estimated 68% of the excess deaths were linked to service disruptions due to COVID-19. The pandemic diverted resources, overwhelmed health systems, and exacerbated inequalities, not only for malaria, but also for HIV and tuberculosis.
Even before COVID-19, concerns had been voiced about the slowed progress of malaria programmes. Nevertheless, in 2019 a Lancet Commission on malaria eradication reaffirmed that eradication—an ambitious permanent reduction of the global incidence to zero—is possible, worthwhile, affordable, and necessary. It recommended an immediate, firm commitment to malaria eradication, especially an increase in funding and closer more strategic collaboration between major malaria organisations. And there have been some notable achievements. The WHO European region was certified malaria-free in 2016, as was Sri Lanka in 2016, Argentina in 2019, and China in 2021. However, 96% of the world's malaria cases and deaths each year occur in Africa; it is there that the success or failure will be decided.
Scientific advances are providing new tools for malaria control. RTS,S—the world's first effective malaria vaccine—was approved last year. Last month, The Lancet published results of a clinical trial showing the effectiveness of a new chlorfenapyr long-lasting insecticidal net that could help to mitigate the impact of insecticide resistance among mosquitoes. The roll-out of new interventions such as these is crucial to curtail malaria mortality, but it is not possible without funding.
In December, 2021, the Gavi board approved an initial investment for the procurement and delivery of RTS,S to sub-Saharan Africa. Later this year, the Global Fund will host its seventh replenishment meeting. It is asking for US$18 billion to support its 2024–26 programmes for malaria, HIV, and tuberculosis, to strengthen health systems, and to reinforce pandemic preparedness. Modelling by the Global Fund predicts that, if it is fully funded, the malaria mortality rate would drop by 66% by 2026, and case incidence by 69%. By contrast, a counterfactual scenario of continued COVID-19 disruption would see a rapid and severe resurgence of malaria deaths and cases, resulting in an additional 2 million deaths and 654 million cases that could have been avoided. The replenishment scenario makes ambitious assumptions about the scale-up of malaria treatment and bednet distribution, as well as roll-out of the RTS,S vaccine. But the model presents countries and donors with a stark choice.
The case for commitment to investment and global collaboration for malaria is clear. Although COVID-19 has harmed malaria programmes and squeezed budgets, new technologies mean that 2022 is also a year of opportunity—if the opportunity is taken. To “harness innovation”, as WHO puts it, will require substantial funding support both domestically and from donors. It will also require meaningful policy commitments from countries to reaffirm the idea of ceasing mortality and morbidity due to malaria. The UN Sustainable Development Goal of ending malaria as a public health threat by 2030 is at stake, and, with it, the lives of hundreds of thousands of people each year.
For WHO's strategy for malaria see https://www.who.int/publications/i/item/9789240031357
For the trial of bednets see Articles Lancet 2022; 399: 1227–41
For more on Gavi's investment case for malaria vaccine see https://www.gavi.org/news/media-room/gavi-board-approves-funding-support-malaria-vaccine-roll-out-sub-saharan-africa
For the Global Fund investment case see https://www.theglobalfund.org/media/11798/publication_seventh-replenishment-investment-case_report_en.pdf
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